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Acute limb ischemia (ALI) is relatively uncommon but serious condition. The estimated incidence is 23.3/ 100.000 person years (Baril et al. 2014) (Korabathina et al. 2013). Regardless of any intervention, ALI is linked with significant morbidity and mortality rates. The hospital mortality ranges from 6.3–9% with hospital amputation rate of 6%, and one-year amputation rate 11%, while the one-year mortality could reach up to 41%. ESVS has published guidelines regarding the management of this critical condition (Björck M et al. 2020). The guidelines have adopted the grading system of recommendation strength proposed by the European Society of Cardiology. In essence, the evidence behind each recommendation is given A-C level, where A represents data derived from multiple randomised clinical trials or meta-analyses, B data derived from a single randomised clinical trial or large nonrandomised studies and C consensus of opinion of the experts and/or small studies, retrospective studies and registries. The strength of each recommendation is given I to III class level where class I represents evidence and/or general agreement that a given treatment or procedure is beneficial, useful, and effective, Class II conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure, and Class III evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. Sixty-one recommendations have been proposed, covering various aspects of ALI including epidemiology, clinical presentations, diagnosis and management. Generally speaking, the authors have done excellent effort trying to produce a document that help practitioners to offer best care and aid in decision making process. The purpose of this editorial is to comment on few specific points, namely the use of what is called “hybrid theatre” and “hybrid treatment” of ALI. Hybrid theatre is a vague term with no clear or agreed definition. It has been frequently used to serve certain political agenda. The best and only respected definition of the term “hybrid theatre” comes from the Medicine and Health Regulatory Agency of United Kingdom (Medicines and Health Products Regulatory Agency (MHRA) 2010), following collaborative work from MHRA, British Society of Interventional Radiology, Royal College of Radiologists, and Vascular Society of Great Britain and Ireland. It states that the facility offering endovascular aortic repair should encompass beside best imaging equipment, theatre specifications including proper ventilation, lights, resuscitation trolleys, infection control measures, equipment stock and backup facility. There is no agreed specific area of the foot print, but area ranges from 45 to 58m thought to be adequate. In that sense almost all modern angiosuites in the Western World have these criteria and can be called “hybrid” theatres. The question of cost effectiveness of location and multipurpose use of “hybrid” theatre is much more controversial and beyond the scope of this editorial (Fletcher et al. 2017) (Field et al. 2009). What about the term “hybrid treatment”?. Recommendation 14 and related discussion states “that patients with acute limb ischaemia should have access to treatment in a hybrid theatre/ operating theatre with C arm equipment, and by a clinical team able to offer a full range of open or endovascular interventions during a

European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of acute limb ischaemia; a word of caution!